Lessons from a first patient
Patients are the best teachers. Former President Bill Clinton's heart saga--which played out to a happy ending this past week with the help of an expert medical team from New York-Presbyterian Hospital--is a vivid medical case that middle-aged Americans should study closely.
At the press conference just after Clinton's Labor Day operation, one could hear the gasps when cardiac surgeon Craig Smith said that he had performed a routine quadruple coronary bypass operation. In the operating room, routine is good. But to most people, and certainly to a presidential baby boomer famous for his vigor, four seriously blocked arteries is no everyday event. Indeed, the former president had a particularly close call. A disease that's been building up for years without a whiff of symptoms took a bad turn several months ago--a turn, as his cardiologist, Allan Schwartz, noted, that brought him to the brink of a major heart attack--or worse.
Atherosclerosis is the disease, and the bad turn very likely came when the surface of a crusty, cholesterol-filled, atherosclerotic plaque began to erode or erupt. This then triggered blood clots and constricted blood flow further so it could not manage the heart's full demands. When the heart becomes starved for oxygen, it sends out an SOS signal in the form of chest tightness or pain, called angina; if the area of the heart struggling for oxygen is large enough, the tightness comes with shortness of breath. As the blockage gets worse, so do the symptoms. The angina starts with exercise, then accompanies normal activity like walking, then occurs even when resting. Bill Clinton experienced this classic pattern and signed himself into a hospital, just in the nick of time.
Now that the first patient is well into recovery, let me suggest, as a cardiologist, what others can take to their own hearts from his:
Know your numbers. That means blood pressure, good and bad cholesterol, weight, and time spent exercising per week. If any are out of whack (in Clinton's case, most were), work with your doctor to get them right.
Genes can be a major risk factor, but their impact can be modified: If heart disease runs in your family, go after what you can control--even those cigars.
Don't stop your cholesterol-lowering statins and turn to South Beach. This diet is high in animal protein and easily serves up twice as much cholesterol as you should have. A few months of this won't do harm, but it makes no sense if you're a statin dropout. Fad diets don't keep pounds off anyway, as Clinton learned.
Don't dismiss exercise-related chest pain as acid reflux, especially if you are over 50 and loaded with heart risk factors. It is natural to deny and wish away strange feelings in your body, but you don't need to wait until they take your breath away.
Listen to your body. Even if you aced your stress test, if symptoms persist or get worse, keep pushing your doctors for answers. At least 10 percent of normal stress tests miss a serious heart problem, as happened with Clinton. Next steps might include a repeat study, a special scan called spiral CT--or the more invasive but gold-standard coronary angiogram.
If you need a heart operation, seek out hospitals and doctors who've done lots of them and done them well: Ask around and look on the Internet. And by the way, most of your bypass grafts should be from arteries rather than from veins. Arteries are harder to work with, but they last for decades. (Three of Clinton's four blocked vessels were repaired arteries.)
Type A personalities do well when they get religion. Within hours of knowing his diagnosis, the ex-president was on TV worldwide with Larry King. Upbeat and in control, he was ready to be fixed up, get back, and "see what it's like to run 5 miles again." Just watch. He will be back under full steam in a month, and that's OK. It's the controlling, stubborn, can-do types who love life and reject victimhood who become icons of good health habits. Especially when they've seen the alternative.
With his wry humor Clinton told King, "Republicans aren't the only people who want four more years here." With his nicely mended heart, our former president should expect 30 or 40 more--provided he heeds his own hard-earned lessons.
This story appears in the September 20, 2004 print edition of U.S. News & World Report.
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